|LETTER TO EDITOR
|Year : 2016 | Volume
| Issue : 2 | Page : 68-69
Transurethral Resection of Prostate is Still the Gold Standard for Small to Moderate Sized Prostates
Nandan R Pujari
Department of Urology, MGM Medical College, Kamothe, Navi Mumbai, Maharashtra, India
|Date of Web Publication||26-Apr-2016|
Nandan R Pujari
Department of Urology, MGM Medical College, Kamothe, Navi Mumbai, Maharashtra
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Pujari NR. Transurethral Resection of Prostate is Still the Gold Standard for Small to Moderate Sized Prostates. J Integr Nephrol Androl 2016;3:68-9
|How to cite this URL:|
Pujari NR. Transurethral Resection of Prostate is Still the Gold Standard for Small to Moderate Sized Prostates. J Integr Nephrol Androl [serial online] 2016 [cited 2020 Jul 4];3:68-9. Available from: http://www.journal-ina.com/text.asp?2016/3/2/68/181223
Transurethral resection of the prostate (TURP) to treat benign prostatic hyperplasia has been the gold standard for decades.  TURP was first performed by Guyon in Paris in 1901. It is efficient and cost-effective with low complication rate.  The complications of TURP include TUR syndrome (0.0-1.4%), UTI (3.6-4.2%), bleeding requiring transfusion (2-2.9%), surgical revision (1-5.6%), failure to void (4.5%), and urethral stricture formation (2.2-9.8%). , Bipolar TURP (B-TURP) has an improved safety profile compared to monopolar TURP.  The principal advantage is the use of isotonic irrigating fluid, which eliminates the risk of electrolytic disturbance from systemic uptake, such as TUR syndrome. There is a 2% decreased risk of TUR syndrome and 5% reduced the risk of clot retention in B-TURP.  Perioperative complications (acute urinary retention, clot retention, and urinary tract infection) were significantly less common in B-TURP (12% vs. 18%), as well as late complications (bladder neck stenosis, urethral stricture, and reintervention) (3.5% vs. 10.5%). Thus, B-TURP is the next generation "gold standard" for benign prostatic obstruction (BPO) because it is associated with a lower rate of clinically relevant complications.  In summary, for over ten decades, TURP and its modifications have been considered the cornerstone of surgical management for BPO and have stood the test of time with documented data of efficacy and safety.
Holmium laser enucleation of the prostate (HoLEP) has emerged as a surgical alternative to TURP. Gilling and Fraundorfer first reported about HoLEP in 1998.  The HoLEP technique is a method of removing the entire prostatic adenoma endoscopically. The HoLEP procedure is composed of enucleation of the prostate adenoma and morcellation of the adenoma within the bladder.
A major disadvantage of HoLEP concerns overcoming the steep learning curve. There is a higher incidence of stress urinary incontinence after HoLEP (10-15%) as compared to TURP, especially in patients with larger prostates (>100 g). Surgical technique of HoLEP tends to induce a higher rate of incontinence than does TURP with the condition lasting longer. , The duration of postoperative incontinence is usually 3-6 months. Some surgeons reported permanent incontinence. The operating time is considerably longer in HoLEP.  Urgency symptoms were more pronounced after HoLEP compared to TURP in a meta-analysis (5.6% vs. 2.2%).  The most dangerous complication that can develop in HoLEP is bladder injury during morcellation. In general, its frequency is around 10% depending on the experience of the surgeon. Other postoperative complications are transient incontinence (8.5%), urinary retention (4.3%), urinary tract infection (1.2%), and urethral stricture (0.6%). HoLEP has been around for more than 17 years but has not been able to replace TURP as the procedure of choice for small to medium sized prostates.
TURP is still the gold standard even now for small to moderate sized prostate glands which comprise the vast majority of cases in any urology practice. HoLEP has not been able to replace TURP as the gold standard in this regard. TURP is a basic surgery which urology residents have to learn and master and should not be misled by the vast literature and hype about HoLEP. HoLEP may be considered equivalent to B-TURP in a small percentage of patients with large prostate glands wherein it obviates the need for open prostatectomy. 
In a meta-analysis, there was no difference in early and late postoperative complications between the two techniques.  The shorter catheterization time, shorter hospital stay and lesser blood transfusions described with HoLEP is not statistically significant.  HoLEP is associated with longer operating time and postoperative dysuria. 
TURP is considered the "benchmark for surgical therapies" by the American Urological Association.  The European Urological Association considers TURP "the treatment of choice for prostates sized 30-80 mL." 
TURP and HoLEP have equivalent outcomes for prostate size <60 g.  The surgical cost incurred for performing a HoLEP is many times that of B-TURP due to the cost of the high powered laser. There is the added cost of the laser fiber and the morcellator. In small to moderate sized prostates <80 g, there is no scientific justification for advising HoLEP. In developing countries where availability of high power lasers is limited due to financial constraints, TURP has stood the test of challenges by many modalities and has been the benchmark for prostate surgery for decades for many more years to come till a superior method is conceived.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Gupta NP, Anand A. Comparison of TURP, TUVRP, and HoLEP. Curr Urol Rep 2009;10:276-8.
Reich O, Gratzke C, Bachmann A, Seitz M, Schlenker B, Hermanek P, et al.
Morbidity, mortality and early outcome of transurethral resection of the prostate: A prospective multicenter evaluation of 10,654 patients. J Urol 2008;180:246-9.
Madersbacher S, Marberger M. Is transurethral resection of the prostate still justified? BJU Int 1999;83:227-37.
Xie CY, Zhu GB, Wang XH, Liu XB. Five-year follow-up results of a randomized controlled trial comparing bipolar plasmakinetic and monopolar transurethral resection of the prostate. Yonsei Med J 2012;53:734-41.
Mamoulakis C, Ubbink DT, de la Rosette JJ. Bipolar versus monopolar transurethral resection of the prostate: A systematic review and meta-analysis of randomized controlled trials. Eur Urol 2009;56:798-809.
Tang Y, Li J, Pu C, Bai Y, Yuan H, Wei Q, et al.
Bipolar transurethral resection versus monopolar transurethral resection for benign prostatic hypertrophy: A systematic review and meta-analysis. J Endourol 2014;28:1107-14.
Gilling PJ, Fraundorfer MR. Holmium laser prostatectomy: A technique in evolution. Curr Opin Urol 1998;8:11-5.
Tan AH, Gilling PJ, Kennett KM, Frampton C, Westenberg AM, Fraundorfer MR. A randomized trial comparing holmium laser enucleation of the prostate with transurethral resection of the prostate for the treatment of bladder outlet obstruction secondary to benign prostatic hyperplasia in large glands (40 to 200 grams). J Urol 2003;170(4 Pt 1):1270-4.
Kuo RL, Paterson RF, Siqueira TM Jr., Watkins SL, Simmons GR, Steele RE, et al.
Holmium laser enucleation of the prostate: Morbidity in a series of 206 patients. Urology 2003;62:59-63.
Wilson LC, Gilling PJ, Williams A, Kennett KM, Frampton CM, Westenberg AM, et al.
A randomised trial comparing holmium laser enucleation versus transurethral resection in the treatment of prostates larger than 40 grams: Results at 2 years. Eur Urol 2006;50:569-73.
Ahyai SA, Gilling P, Kaplan SA, Kuntz RM, Madersbacher S, Montorsi F, et al.
Meta-analysis of functional outcomes and complications following transurethral procedures for lower urinary tract symptoms resulting from benign prostatic enlargement. Eur Urol 2010;58:384-97.
Gupta NP, Nayyar R. Management of large prostatic adenoma: Lasers versus bipolar transurethral resection of prostate. Indian J Urol 2013;29:225-35.
Li S, Zeng XT, Ruan XL, Weng H, Liu TZ, Wang X, et al.
Holmium laser enucleation versus transurethral resection in patients with benign prostate hyperplasia: An updated systematic review with meta-analysis and trial sequential analysis. PLoS One 2014;9:e101615.
Yin L, Teng J, Huang CJ, Zhang X, Xu D. Holmium laser enucleation of the prostate versus transurethral resection of the prostate: A systematic review and meta-analysis of randomized controlled trials. J Endourol 2013;27:604-11.
McVary KT, Roehrborn CG, Avins AL, Barry MJ, Bruskewitz RC, Donnell RF, et al
. American Urological Association Guideline: Management of Benign Prostatic Hyperplasia (Revised 2010). Available from URL: http://www.auanet.org/common/pdf/education/clinical-guidance/Benign-Prostatic-Hyperplasia.pdf. [Last Accessed on 2016 April 20].
Gravas S, Bach T, Bachmann A, Drake M, Gacci M, Gratzke C, et al
. European Association of Urology Guidelines: Treatment of Non-neurogenic Male LUTS. Available from URL: https://uroweb.org/guideline/treatment-of-non-neurogenic-male-luts/#5. [Last Accessed on 2016 April 21].